ATTACHMENT F_PAST PERFORMANCE QUESTIONNAIRE NX EQ Ophthalmic Perimeters.pdf
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- Attached to
- NX EQ Ophthalmic Perimeters
- Solicitation number
- 36C10G25R0035
About this file
This document is a Past Performance Questionnaire for a Department of Veterans Affairs (VA) Strategic Acquisition Center (SAC) solicitation seeking ophthalmic equipment (Zeiss® brand or equal). The questionnaire is designed for references to provide detailed performance evaluations of potential vendors across four key rating categories: Quality of Service, Cost Control, Timeliness of Performance, and Business Relations. References are asked to rate vendors on a scale from 1 (Unsatisfactory) to 3 (Excellent) and provide comments, with a specific focus on the vendor's contract compliance, cost management, milestone achievement, and overall reliability.
The solicitation (No. 36C10G25R0035) requires offerors to submit up to five references from the past three years, with the completed questionnaire to be emailed to Alex Beck and Sara Vickroy by June 03, 2024, at 11:59 PM EST. The evaluation form includes sections for references to document contract details such as performance period, total contract value, and whether options were exercised, as well as a final section asking whether the reference would choose to work with the offeror again. This questionnaire will be used by VA evaluators to assess potential vendors' past performance for the NX EQ Ophthalmic equipment procurement.
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Attachment F Past Performance Questionnaire
SOLICITATION NO.: 36C10G25R0035
DESCRIPTION: NX EQ Ophthalmic – Zeiss® Brand Name or Equal
Offerors: Please Send to Each Reference Cited in Submitted Proposal (Maximum of Five References from Past Three Years)
DEPARTMENT OF VETERANS AFFAIRS (VA)
STRATEGIC ACQUISITION CENTER (SAC)
PAST PERFORMANCE QUESTIONNAIRE
TO: Alex Beck E-MAIL: Alex.Beck1@va.gov
VA SAC is currently in the process of awarding a contract for the solicitation described above.
The offeror identified below has provided your organization’s name as a reference under the contract described below:
Offeror Name:
(Insert Offeror’s Name Here)
Contract Number: (Insert Applicable Contract Number Here)
Please rate the offeror in each of the categories on this questionnaire. See “Rating Guidelines” section for detailed description of categories and ratings. There is room for comments where you deem remarks would be helpful to our evaluation (see ‘Comment from Reference’ under “Offeror Evaluation.” Please note that the past performance evaluators for this solicitation may contact you for further details in making a fair assessment of this offeror’s past performance. Thank you for your organization’s assistance in fairly evaluating offeror proposals for this solicitation.
Please E-mail Questionnaire to Alex.Beck1@va.gov and Sara.Vickroy@va,gov by June 03, 2024, at 11:59 PM EST.
Name of Reference: (Reference Complete These
Sections) Title of Reference:
Phone Number:
E-Mail Address:
Name of Organization:
Contract Period of Performance (Month/Day/Year Begin and End):
Total Contract Value (Base and All Option Years):
Options Exercised on Contract (Yes/No)?
Brief Description of Services/Commodity Provided by Offeror:
Show Cause Order Issued on Contract (Yes/No)?
Stop Work Order Issued on Contract (Yes/No)?
mailto:Alex.Beck1@va.gov
Termination for Convenience, Cause, or Default Issued on Contract (Yes/No)?
Rating Guidelines:
Rating Quality of
Service Cost Control
Timeliness of Performance
Business Relations
1: Unsatisfactory Offeror is not in compliance and has jeopardized achievement of contract objectives
Offeror is unable to manage costs effectively
Offeror delays have jeopardized performance
Responses to inquiries and issues are not effective
2: Satisfactory Minor inefficiencies and errors have been identified
Offeror is usually effective in managing costs
Offeror is usually effective in meeting milestones and delivery schedule
Responses to inquiries and issues is usually effective
3: Excellent Offeror is in compliance with contract requirements and delivers quality services
Offeror is effective in managing costs and submits proper invoices
Offeror is effective in meeting and exceeding milestones and delivery schedule
Responses to inquiries have been effective and/or exceeded expectations and established deadlines
Offeror Evaluation:
Rating (List Number Based on Rating Guidelines Above)
Category Description
Quality of Service
In compliance with contract requirements, submits accurate reports/deliverables, has effective personnel, and has achieved/maintained technical excellence:
Comment from Reference: _______________________
Cost Control Has achieved efficiencies in costs, managed costs effectively, and has submitted timely/accurate invoices with supporting documentation:
Timeliness of
Performance Has met milestones, is reliable, is responsive to technical direction, and has completed milestones on-time or ahead of schedule:
Business Relations
Has maintained effective management of contract, has exhibited reasonable/cooperative behavior, is responsive to contract requirements, is responsive to inquiries/issues, and is proactive about resolving problems:
YES NO Overall Satisfaction
Would you (reference) choose to work with this offeror again?
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